Biomedical subjects

Debra Kerr

Publications and source records attributed to Debra Kerr.

12 recordsLinked to original sources

PubMed2006

One-handed versus two-handed chest compressions in paediatric cardio-pulmonary resuscitation.

OBJECTIVES: To determine emergency department (ED) staff preference for one- or two-handed paediatric chest compressions and to determine if there was a difference in compression rates delivered and fatigability between the techniques. METHODS: This was a randomised, cross-over observational study of paediatric CPR performed on a standard paediatric manikin by ED staff. Consenting, eligible staff [ED doctors and nurses] performed CPR in pairs with chest compressions delivered using a one- and two-handed technique. The outcomes of interest were compression rates for one- and two-handed CPR, decrease in compression rate over time for each technique and staff preference for technique. Data was analysed using descriptive statistics, Chi Square test and Mann-Whitney U-test as appropriate. RESULTS: Sixty-two ED staff participated in the study. Compression rates with both techniques were similar and higher than guidelines recommend (133.6 min(-1) for one-handed and 135.7 min(-1) for two-handed respectively). The compression rate slowed by 6.9 compressions/min over 1 min in one-handed compressions compared with 2.6 compressions/min in two-handed compressions (p = 0.0264). 65.6% of participants reported that they preferred the two-handed compression technique. CONCLUSION: This study showed that CPR compression rate is similar with one- and two-handed compression techniques, but compression rate decreased more quickly with the one-handed technique. The majority of staff preferred the two-handed compression technique for reasons of ease, control and uniformity with other CPR techniques.

Cardiopulmonary Resuscitation↗

PubMed2006

Adverse events associated with the use of intravenous epinephrine in emergency department patients presenting with severe asthma.

STUDY OBJECTIVE: We determine the rate of adverse effects associated with the use of intravenous (IV) epinephrine by infusion for the treatment of severe asthma in the emergency department (ED). METHODS: This retrospective, structured, medical record review included adult patients who presented to the ED of Western Hospital between 1998 and 2003 and who were triaged as category 1, 2, or 3, had a discharge diagnosis of asthma, and were administered IV epinephrine in the ED. Patients were excluded if they were older than 55 years or if a diagnosis of asthma was not confirmed. The primary outcome measures were occurrence of cardiac arrhythmia or ischemia, local tissue ischemia, hypotension or hypertension, neurologic injury, or death related to epinephrine infusion. RESULTS: Two hundred twenty episodes of care met the inclusion criteria. Adverse events occurred in 67 episodes (30.5%; 95% confidence interval [CI] 24.5% to 37.1%); however, most were minor and self-limiting. There were no deaths. Major adverse events occurred in 3.6% of cases (8/220; 95% CI 1.7% to 7.3%), including 2 cases of supraventricular tachycardia, 1 case of chest pain with ECG changes, 1 case of incidental elevated troponin, and 4 cases of hypotension requiring intervention. CONCLUSION: IV epinephrine is associated with a low rate of major and a moderate rate of minor adverse events in patients with severe asthma; however, a causal relationship has not been established. Further research investigating effectiveness, as well as safety, is warranted.

Acute Disease↗

PubMed2006

Head computed tomography guidelines are being followed.

OBJECTIVE: Several guidelines have been developed to direct the ordering of head computed tomography (CT) for patients, but most are clinical presentation-specific. Recently, an integrated guideline for ordering emergent head CT for patients who present to the ED of Western Hospital, Footscray, Victoria, Australia, was developed in response to concerns raised regarding perceived over-utilization of head CT for ED patients. Our aim was to determine compliance with the guideline. METHODS: This was an explicit retrospective medical record review of patients who presented to the ED of Western Hospital between 1/04/2004 and 17/6/2004 and had a head CT as part of their assessment. Clinical information for these cases was compared with guideline recommendations. Data are described by descriptive statistics. RESULTS: Of the 231 cases that were included in the study, 65 (28.1%, 95% confidence interval 23-35%) had abnormal CT findings. Guidelines were adhered to in 217 (93.9%, 95% confidence interval 91-97%) cases. For the cases where the guidelines were not adhered to (14; [6.1%]), there was only one abnormal scan the clinical significance of which is not clear. CONCLUSION: The study found that compliance with head CT guideline was high. This suggests that the guideline is both clinically relevant and supported by ED doctors or conversely that the guideline is concordant with existing ordering practices of the ED.

Adolescent↗

PubMed2005

Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose.

OBJECTIVE: To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting. DESIGN: Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser. PARTICIPANTS AND SETTING: 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria. MAIN OUTCOME MEASURES: Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment. RESULTS: The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%. CONCLUSION: IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.

Administration, Intranasal↗

PubMed2005

The quality of medical record review studies in the international emergency medicine literature.

STUDY OBJECTIVE: We assess the methodologic quality of studies using medical record review methodology in 4 international emergency medicine journals. A secondary aim was to compare methodology quality among these journals and across years. METHODS: This was an observational study of articles whose main methodology was medical record review published in Academic Emergency Medicine (AEM) , Annals of Emergency Medicine (Annals) , Emergency Medicine Journal (EMJ) , and Emergency Medicine Australasia (EMA) between January 2002 and May 2004. Eligible articles were reviewed for reporting of a clear hypothesis or objective, training of abstractors, defined inclusion and exclusion criteria, use of a standard abstraction form, definition of important variables, monitoring of abstractor performance, blinding of abstractors to study hypothesis, reporting of interrater reliability, sample size or power calculation, reporting of ethics approval or waiver, and disclosure of funding source. The primary outcome was the proportion of articles meeting each criterion. Secondary outcomes were comparison of the proportions of articles meeting each criterion among journals and by years. RESULTS: One hundred seven articles were analyzed; 31 were published in AEM, 29 in Annals, 29 in EMJ, and 18 in EMA . A clear aim was reported in 93% of articles, standardized abstraction forms were reported in 51%, interrater reliability was reported in 25%, ethics approval or waiver was reported in 68%, and sample size or power calculation was reported in 10%. CONCLUSION: Adherence to the quality criteria for medical record reviews was suboptimal, and there were significant differences among journals in overall methodologic quality.

Emergency Medicine↗

PubMed2005

Implementation of the Canadian C-spine rule reduces cervical spine x-ray rate for alert patients with potential neck injury.

The objectives of this before-and-after study of alert, stable adult patients presenting to the Emergency Department of Western Hospital with potential neck injuries who were immobilized in hard cervical collars were to determine the impact of implementation of the Canadian C-spine rule on x-ray ordering rates and whether implementation of the rule reduced time in hard collars for patients with potential neck injury. Data collected included demographics, mechanism of injury, x-ray rate, and time in hard collar. Data analysis was by chi-square test for proportions and Mann-Whitney U test for continuous variables. There were 211 patients studied. The x-ray ordering rate decreased from 67% to 50% (25% relative reduction, p = 0.0187). Time in hard collar was also reduced from a median of 128 min to a median of 103 min (effect size 25.5 min), but this did not reach statistical significance. Implementation of the Canadian C-spine rule reduced x-ray ordering by 25%.

Adolescent↗

PubMed2005

Validation of venous pCO2 to screen for arterial hypercarbia in patients with chronic obstructive airways disease.

To validate a previously derived venous pCO2 (pvCO2) cut-off for ruling out arterial hypercarbia in patients with chronic obstructive pulmonary disease (COPD), matched arterial and venous blood gas samples were taken from a convenience sample of patients who presented to the Emergency Department (ED) with COPD deemed by their treating doctor to require arterial blood gas (ABG) analysis as part of their care. The screening cut-off was defined as pvCO2 of > 45 mm Hg and arterial hypercarbia was defined as arterial pCO2 (paCO2) of > 50 mm Hg. Descriptive statistics were employed. Sensitivity, specificity and negative predictive value were calculated. There were 112 patients enrolled in the study, of whom 107 had complete data for analysis. Forty-three patients had arterial hypercarbia (range of 51 to 90 mm Hg, median 60 mm Hg). All cases of arterial hypercarbia were detected by the screening cut-off (sensitivity 100%; 43/43; 95% CI 91-100%; specificity 47%, 95% CI 35-59%). The negative predictive value of pvCO2 < 45 mm Hg was 100% (30/30, 95% CI 89-100%). Assuming the ABG was performed to assess hypercarbia, 29% of ABGs potentially could have been avoided if a venous screening test was employed. In conclusion, pvCO2 can be used as a screening test for arterial hypercarbia, and if employed, can potentially reduce the requirement for ABG sampling.

Aged↗

PubMed2004

Is severity assessment after one hour of treatment better for predicting the need for admission in acute asthma?

AIM: To determine if severity assessment after 1 h of treatment is better than assessment at presentation for predicting the requirement for hospital admission for emergency department (ED) patients with acute asthma. METHODS: Prospective, observational study conducted in 36 Australian ED for a 2-week period in 2001 involving patients aged 1-55 years presenting with asthma. Data collected included severity assessment according to the National Asthma Guidelines (Australia) at presentation and 1 h, and disposition. Descriptive analysis was applied. RESULTS: 720 cases were analysed. Patients with 'mild' asthma at either assessment time had a greater than 80% chance of discharge home. Patients assessed as 'severe' at either assessment had a greater than 85% chance of requiring hospital admission, but the 1 h assessment was better at predicting the need for Intensive Care Unit (ICU) admission. For the 'moderate' group, the initial assessment was a poor predictor of the need for admission however those who met the criteria for 'moderate' severity at 1 h had an 84% chance of requiring admission. CONCLUSION: Assessment of asthma severity after 1 h of treatment is better than initial severity assessment for determining the need for hospital admission for patients initially assessed as having 'moderate' asthma and for predicting the need for ICU in patients initially assessed as 'severe'.

Acute Disease↗

PubMed2003

Call-to-needle times for thrombolysis in acute myocardial infarction in Victoria.

OBJECTIVE: To determine the proportion of patients in Victoria treated within the British Heart Foundation 90-minute call-to-needle (CTN) time benchmark for thrombolysis of ST-elevation myocardial infarction (STEMI), and to validate the British Heart Foundation 90-minute benchmark with respect to mortality. DESIGN: Cohort study. SETTING: 20 hospitals and two ambulance services in the State of Victoria, Australia. PARTICIPANTS: 1147 patients with STEMI transported to hospital by ambulance and eligible for thrombolysis. MAIN OUTCOME MEASURES: CTN time, and in-hospital mortality. RESULTS: Median CTN time was 83 minutes (mean, 93.2 min; range, 29-894 min). Median door-to-needle (DTN) time was 37 minutes (mean, 46.5 min; range, 0-853 min). 61% of patients received thrombolysis within the 90-minute benchmark. Patients with CTN times > 90 minutes had an increased risk of dying (relative risk, 1.8; 95% CI, 1.3-2.7). Factors associated with CTN time < 90 minutes were lower DTN time, prior notification of the receiving hospital and transport time less than 20 minutes. CONCLUSION: The British Heart Foundation CTN time benchmark is being met for 61% of eligible STEMI patients in Victoria. Strategies to reduce CTN time should be region-specific, and should include attempts to reduce DTN and to enhance ambulance-hospital communication. Prehospital thrombolysis may be appropriate for some regions.

Adult↗

PubMed2003

Lack of agreement in classification of the severity of acute asthma between emergency physician assessment and classification using the National Asthma Council Australia guidelines (1998).

AIMS: To determine the level of agreement in classification of the severity of acute asthma at presentation to the emergency department, between emergency physician global assessment and severity classification according to the National Asthma Council Guidelines, Australia 1998 (NACG). METHODS: Prospective observational study in emergency departments throughout Australia, participating in the Asthma Snapshot 2000 project. Patients between the ages of one and 60 years presenting to participating emergency departments with acute asthma between 21 August and 3 September 2000 were included. Data collected were emergency physician global assessment of asthma severity and severity classification according to the National Asthma Council Guidelines and disposition. RESULTS: Five hundred and five subjects had completed data for emergency physician assessment of severity and for calculation of severity classification according to the National Asthma Council Guidelines. Weighted kappa for agreement in classification was 0.48 (95% confidence interval: 0.40, 0.56). Emergency physicians assess asthma as less severe compared to the National Asthma Council Guidelines assessment. CONCLUSIONS: Agreement between physician assessment of severity of acute asthma and severity classification according to National Asthma Council Guidelines is only moderate. This may have implications in treatment and disposition. This also suggests that emergency physicians may be using other methods to classify acute asthma than the National Asthma Council Guidelines classification.

Asthma↗

PubMed2002

Patients with a longer duration of symptoms of acute asthma are more likely to require admission to hospital.

OBJECTIVE: To determine whether, for patients with moderate or severe asthma presenting to emergency departments, there is a difference in need for hospitalization between those with a duration of symptoms less than 6 h and those with a longer duration of symptoms. METHODS: This prospective, observational study investigated a sample of patients presenting with acute asthma between 21 August and the 3 September 2000, attending study emergency departments and classified as having moderate or severe asthma according to the National Asthma Guidelines. Data collected included duration of symptoms (less than 6 h or greater than 6 h) and disposition following emergency department treatment (home, ward, intensive care unit, high dependency unit, transfer). Data analysis was by Chi square analysis. RESULTS: Of 381 eligible patients, 348 had sufficient data for entry into this study (33 had missing data). Patients with duration of symptoms more than 6 h were more likely to require hospital admission (P < 0.0001). The relative risk for hospital admission or transfer as opposed to discharge from the emergency department for the group with a duration of symptoms of more than 6 h was 2.2. CONCLUSION: Patients presenting with moderate or severe asthma and a duration of symptoms of more than 6 h are more likely to require hospital admission or transfer for further treatment than patients with a shorter duration of symptoms. This has implications for decision making regarding asthma management and disposition in the emergency department.

Acute Disease↗

PubMed2002

Validation of a tool to safely triage selected patients with chest pain to unmonitored beds.

OBJECTIVE: To externally validate a chest pain protocol that triages low risk patients with chest pain to an unmonitored bed. METHODS: Retrospective study of all patients admitted from the emergency department of a tertiary referral public teaching hospital with an admission diagnosis of 'unstable angina' or suspected ischemic chest pain. Data was collected on adverse outcomes and analysed on the basis of intention-to-treat according to the chest pain protocol. RESULTS: There were no life-threatening arrhythmias, cardiac arrests or deaths within the first 72 h of admission in the group assigned to an unmonitored bed by the chest pain protocol ([0/244]; 0.0%: 95% confidence interval 0.0-1.5%). Four patients had an uncomplicated myocardial infarction, two patients had recurrent ischemic chest pain and one patient developed acute pulmonary oedema ([7/244]; 2.9%: 95% confidence interval 1.2-5.8%). CONCLUSION: This retrospective study externally validated the chest pain protocol. Care in a monitored bed would not have altered outcomes for patients triaged to an unmonitored bed by the chest pain protocol. Compared to current guidelines, application of the chest pain protocol could increase the availability of monitored beds.

Aged↗